Abstract
Chronic rhinosinusitis is very common disorder encountered in general population. Anatomical variations in the nasal cavity are mainly responsible for improper drainage and subsequent chronic rhinosinusitis. Present study is crosssectional and observational study undertaken at ENT department of tertiary care hospital. 200 cases of chronic rhinosinusitis fulfilling inclusion criteria were evaluated for various anatomical variations in the nasal cavity using diagnostic nasal endoscopy and computed tomography. Present study of 200 cases showed male preponderance M: F ratio 1:0.56. Most cases (79.5%) belonged to age group 11–50. Nasal obstruction was presenting complaint in 90% cases. 78% cases had septal deviation. 20% had septal spur. 32% cases had enlarged inferior turbinate, 9% had paradoxical middle turbinate, 13% had enlarged middle turbinate, 1% had bifid middle turbinate. 12% had pneumatised middle turbinate. 7% had enlarged uninate process, 1.5% cases had hypoplastic uncinate process and 7% had enlarged ethmoidal bulla. 45% cases showed oval sphenoid ostium while 31% showed circular and 8% slit like opening. Agger nasi cells were present in 82% cases. All 200 cases had anatomical variations in nasal cavity so it can be concluded that these are responsible for chronic rhinosinusitis
Keywords: Chronic rhinosinusitis, Septal deviation, Conchabullosa, Agger nasi cells, Osteomeatal complex
Introduction
Anatomical variations in the nasal cavity are extremely important since they play important role in functioning of nose and paranasal sinuses. The two cardinal factors in the maintainance of normal physiology of the nose and paranasal sinuses are drainage and ventilation. Normal drainage depends on effective mucociliary clearance; This is dependent, among other things, such as the condition of sinus ostia, its inflammation and obstructive anatomical variations in nasal cavity. Mucus transport from the sinuses into the nose is greatly enhanced by unimpended nasal airflow creating negative pressure within the nasal cavity during inspiration [1].
The secretions of the various sinuses do not reach their respective ostia randomly but by definite pathways [2]. The two of the largest sinuses, the frontal and maxillary communicate with the middle meatus via narrow and delicate prechambers like middle meatus and frontal recess [3]. In middle meatus and frontal recess, the mucosal surfaces are closely opposed such that mucus can be more readily cleared by an effective ciliary action on two or more sides. However, when surfaces become more closely apposed, the ciliary action is hampered. This impairs the ventilation and drainage of larger sinuses, result in mucus stasis, predisposes to further infection and establishes a vicious cycle causing chronic rhinosinusitis [4]. The key region for these changes is part of the lateral nasal wall which encloses the sinus ostia, their adjacent mucosa and prechambers. There are considerable anatomical variations that may interfere with normal nasal function and predispose to chronic rhinosinusitis [4].
The incidence with which these variations are seen in a normal population is less frequent than in those individuals with chronic rhinosinusitis [5]. The incidence of the sinonasal anatomical variations reported in literature shows considerable variation between populations. These anatomical variations studied on diagnostic nasal endoscopy and computed tomography scan are found to block the osteomeatal complex (OMC) and cause chronic rhinosinusitis [2]. Currently diagnostic nasal endoscopy and computed tomography scanning are used for evaluation of the nose and paranasal sinuses in patients presenting with symptoms of chronic rhinosinusitis. This gives an applied anatomical view of the region, associated sinonasal pathology and of the anatomical variants that are very often found before planning for surgery. This also minimizes occurrence of complications in Functional Endoscopic Sinus Surgery [2].
The study aims to evaluate the anatomical variations in the nasal cavity by Diagnostic nasal endoscopy and computed tomography in sufferers of chronic rhinosinusitis and frequency of occurrence of these anatomical variations.
Material and Methods
The study aims to evaluate the anatomical variations in the nasal cavity like.
Septal variations a. Deviations. b. Spurs. c. Thickened septum. d. Pneumatisation of septum.
Turbinates a. Middle: Paradoxical, pneumatized, hypertrophy, lateralized.
b. Inferior: Hypertrophied and pneumatized. c. Superior: Pneumatized.
d. Supreme: Presence or absence.
Uncinate process a. Medialized b. Lateralizedc. Anteriorly curved d. Hypertrophied e. Pneumatized.
f. Variations in superior attachment of Uncinate process (to Middle turbinate/to Lamina papyracea/to Skull base/Lying free in middle meatus).
Infundibulum a. Shallow or deep. b. Narrow or wide.
Ethmoidal bulla a. Absent. b. Hypoplastic. c. Typical. d. Enlarged by Diagnostic nasal endoscopy and computed tomography in sufferers of chronic rhinosinusitis and frequency of occurrence of these anatomical variations.
Present study was undertaken in the department of ENT in a tertiary care institute.Approval from the institutional ethical committee was taken before commencing the study.
Study Design
Observational study, cross sectional study.
Duration of Study
2 years from October 2013 to September 2015.
Study Population
Cases attending ENT OPD and fulfilling study criteria during study period at tertiary care institute.
Sample Size
200 cases.
Aims and Objectives
To study age and genderwise distribution of patients with chronic rhinosinusitis
To study the anatomical variations in nasal cavity of patients with chronic rhinosinusitis by Diagnostic Nasal Endoscopy.
To study the anatomical variations in nasal cavity of patients with chronic rhinosinusitis by computed tomography
To determine frequency of occurrence of anatomical variations in nasal cavity in these patients of chronic rhinosinusitis.
Selection of Cases
Cases were selected according to following criterion for the study.
Inclusion Criterion
Patients clinically diagnosed as chronic rhinosinusitis according to following symptoms/signs (requires 2 major symptoms/signs or 1 major and 2 minor) for duration more than 12 weeks [6].
-
Major symptoms/signs
Facial pain/pressure,Facial congestion/fullness,Nasal obstruction/blockage,Nasal discharge/purulence/discoloured posterior discharge, Hyposmia/anosmia and Purulence on nasal examination.
Minor symptoms/signs
Headache, Fever (Nonacute), Halitosis, Fatigue, Dental pain, Cough and Ear pain/pressure/fullness.
Exclusion Criterion
Following cases were excluded from the study.
Patients who have undergone previous nasal surgery, patients with nasal mass, immunocompromised hosts, patients with chronic granulomatous nasal disease. Patients with chronic rhinosinusitis due to allergy, occupational, Nonalleric rhinitis with eosinophilia syndrome, Hormonal causes, Drug induced, Irritants, Food allergy, Atrophic rhinitis and due to Gastro-oesophageal reflux.
A detailed history was asked in every case, general and systemic examination was performed followed by otorhinolaryngological examination. This was followed by computed tomographic examination of nose and paranasal sinuses and diagnostic nasal endoscopic examination. Details of every case was recorded in seprate case proforma. Data was compiled and analysed.
Observations and Results
In current study mean age of presentation was 30.19 years. 79.5% cases belonged to age group11-50 years. There was significant male preponderance seen in the study as 64%cases were males and 36% cases female. Most common presenting complain was nasal obstruction (90%) followed by nasal discharge (80%),headache (56%),snoring (44%) hyposmia (17%) and epistaxis (4%) as shown in Table 1
Table 1.
Presenting complaints
| Sr. No. | Presenting complaint | Number of cases | Percentage |
|---|---|---|---|
| 1 | Nasal obstruction | 180 | 90 |
| 2 | Nasal discharge | 160 | 80 |
| 3 | Headache/facial pain | 112 | 56 |
| 4 | Snoring | 88 | 44 |
| 5 | Hyposmia | 34 | 17 |
| 6 | Epistaxis | 8 | 4 |
In present study 156 (78%) cases had septal deviation, 40 (20%) cases had septal spur.
32% cases had enlarged inferior turbinate, 9% had paradoxical middle turbinate, 13% had enlarged middle turbinate and 1% had bifid middle turbinate on diagnostic nasal endoscopy (Table 2)
Table 2.
Variation in turbinates on Diagnostic nasal endoscopy
| Sr. No. | Variation in turbinates on diagnostic nasal endoscopy | Number of cases | Percentage |
|---|---|---|---|
| 1 | Enlarged inferior turbinate | 64 | 32 |
| 2 | Paradoxical middle turbinate | 18 | 9 |
| 3 | Enlarged middle turbinate | 26 | 13 |
| 4 | Bifid middle turbinate | 2 | 1 |
6% had pneumatised middle turbinate and 4% turbinate sinus on computed tomographic scan.7% cases had enlarged uncinate process and 1.5% Hypoplastic uncinate process on diagnostic nasal endoscopy. Uncinate process was seen attached to middle turbinate in 32% cases, attached to lamina papyracea in 33% cases, attached to skull bas in 23%, lying free in middle meatus12%, hypertrophied in 5% and Pneumatised in 2% cases in computed tomographic study (Table 3)
Table 3.
Variation in uncinate process on CT scan
| Sr. No. | Variation in uncinate process in CT scan | Number of cases | Percentage |
|---|---|---|---|
| 1 | Attached to middle turbinate | 64 | 32 |
| 2 | Attached to lamina papyracea | 66 | 33 |
| 3 | Attached to skull base | 46 | 23 |
| 4 | Lying free in middle meatus | 24 | 12 |
| 5 | Hypertrophied uncinate process | 10 | 5 |
| 6 | Pneumatised uncinate process | 4 | 2 |
14 (7%) had enlarged Ethmoidal bulla and no patient had absent or hypoplastic ethmoidal bulla. 30(15%) cases had Accessory maxillary sinus ostium.
In 90 (45%) cases sphenoid sinus ostium was oval shaped, in 62 (31%) it was circular shaped and in 16 (8%) cases it was slit shaped.
On computed tomographic scan Agger nasi cells were present in 164 (82%) cases and absent in 36 (18%) cases.
Discussion
In present study 200 cases suffering from chronic rhinosinusitis fulfilling study criteria were included.
In present study mean age of presentation was 30.19 years which is comparable to study by Kolvekar et al. [7]. Bajaj et al. [8] study had mean age 38.32.
In present study 64% cases were males and 36% were females which is comparable to study by Bajaj et al. [8] Adeel et al. [9] alwhich also suggest male preponderance. Cobzdanu et al. [10] study showed slight male preponderance.
The most common complaint in the present study was nasal obstruction(90%) followed by nasal discharge (80%) which is comparable to study of Jareoncharsri et al. [11] where 92.8% cases had nasal obstruction and nasal discharge. In study by Asruddin et al. [12] 70% cases had nasal discharge as presenting complaint.
In present study 78% cases had septal deviation which is comparable to study by Aramani et al. [13] and Jareoncharsri et al. [11] where in 74% and 72% cases and septal deviation. In study by Azila et al. [14] 56% cases had septal deviation.
In present study 20% cases had septal spur which is comparable with study by Jareoncharsri P et al. [11] (25.3%) but in contrast to study by Bajaj et al. [8] (47.5%). Danese et al. [15] study showed septal spur in 33% cases.
In present study 6% cases had Concha Bullosa which is comparable with study by Davis et al. [16] and Lothrop et al. [17] where in concha bullosa was seen in 8% and 9% cases respectively. In study by Bajaj et al. [8] 30% cases showed concha bullosa.
In current study 9% cases had paradoxical middle turbinate which is comparable to studies by Fadda et al. [18], Bajaj et al. [8] and Khojastepour et al. [19] where in 6.4%, 8.75% and 10% cases showed paradoxical middle turbinate.
In current study 32% cases had inferior turbinate hypertrophy which is comparable with study by Bajaj et al. [8] where 36.2% cases had inferior turbinate hypertrophy. Stammberger [2] stated that in a vast majority of their cases of inferior turbinate enlargement,there was inflammatory disease in other part of nose.
In present study supreme turbinate was not seen in any case. Bajaj et al. [8] also reported no case with supreme turbinate in their study.
In present study 5% cases had hypertrophied uncinate process which is comparable with study by Armani et al. [13] where in 5.6% cased had hypertrophied uncinate process. In study by Fadda et al. [18] 10% cases had hypertrophied uncinate process.
In present study 2% cases had pneumatised uncinate process which is comparable with study of Asruddin et al. [12] (2%), Bajaj et al. [8] (2.5%) 95, Fadda et al. [18] (2.8%) 1 and Cobzeanu et al. [10] (3.41%).
In present study superior attachment of uncinate process to middle turbinate was seen in 32% cases which is comparable to Bajaj et al. [8] (38.75) cases but in contrast to Tuli et al. [20] (3%)and Vinaykumar [21] (20%). In 33% cases uncinate process was seen attached to lamina papyracea in present study which is comparable to Bajaj et al. [8] (35%) but in contrast to Tuli et al. [20] (67%).It was seen attached to skull base in 23% cases which is comparable to Bajaj et al. [8] (26.25%) but in contrast to Vinaykumar et al. [21] (8%).Uncinate process was lying free in middle meatus in 12% case in present study which is comparable with study by Tuli [20] (16%)
In present study Enlarged ethmoidal bulla was seen in 7% cases which is similar to study by Jaereoncharsri et al. [11] (7.2%) and Asruddin et al. [12] (9%)
In present study Agger Nasi cells were found in 82% cases which is similar with Azila et al. [14] (81.2%) Bajaj et al. [8] found Agger Nasi cells in 72.5% cases
In present study 15% cases has had accessory maxillary sinus ostium which is comparable with study of Earwaker et al. [22] (13.75%) and Kolvekar et al. [7] (13.33%). Bajaj et al. [8] reported accessory maxillary ostium in 22.5% cases.
In present study 45% cases had oval shaped, 31% circular shaped and 8% had slit shped sphenoid sinus ostium which comparable with study of Bajaj et al. [8] where 45.2% cases had oval and 30.6% had circular opening of sphenoid ostium. Berjis et al. [23] reported slit opening in 53.3% cases.
Conclusion
In present study all cases of chronic rhinosinusitis were associated with one or more anatomical variations in the nasal cavity, so it can be concluded that anatomical variations in nasal cavity are responsible for chronic rhinosinusitis. Diagnostic nasal endoscopy aided with computed tomographic scan are important tools for early detection and subsequent appropriate treatment.
Funding
There was no funding of any kind for this study.
Compliance with Ethical Standards
Conflict of interest
There is no conflict of interest of any kind about this study.
Ethical Standards
All procedures performed in present study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of Shri Vasantrao Naik Government Medical College and Hospital,Yavatmal, Maharashtra,India in August 2014.
Footnotes
Publisher's Note
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